regence uniform medical plan

Under state law, the Uniform Medical Plans (UMP Achieve 1, UMP Achieve 2, UMP Classic, UMP CDHP, UMP High Deductible, UMP Plus – Puget Sound High Value Network, and UMP Plus – UW Medicine ACN) must comply with decisions made by the Health Technology Clinical Committee (HTCC). The Uniform Medical Plan (UMP) Pre-authorization List includes services and supplies that require pre-authorization or notification for UMP members. Learn more about this requirement. The specific procedure code(s) must be requested in place of these non-specific codes. This page contains benefit information for 2020. Genetic Testing; Familial Hypercholesterolemia (PDF) - GT11, KRAS, NRAS and BRAF Variant Analysis and MicroRNA Expression Testing for Colorectal Cancer (PDF) - GT13, 81210, 81275,81276, 81311, 81403, 81404, 0111U, Preimplantation Genetic Testing of Embryos (PDF) - GT18, Genetic Testing; IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia (PDF) - GT19, Genetic and Molecular Diagnostic Testing (PDF) - GT20, Code 81225 will deny as not a covered benefit when billed with the following dx: depression, mood disorders, psychosis, anxiety, ADHD and substance use disorders, Genetic Testing for Biallelic RPE65 Variant-Associated Retinal Dystrophy (PDF) - GT21, Gene Expression Profiling for Melanoma (PDF) - GT29, BRAF Genetic Testing to Select Melanoma or Glioma Patients for Targeted Therapy (PDF) - GT41, Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer (PDF) - GT42, Apply the Regence medical policy Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer (PDF) for conditions/treatments not addressed in the HTCC decision (e.g. The Classic and CDHP plans share the same large network that includes providers both nationwide and worldwide. Bariatric surgery and HTCC guidelines apply, in order to establish eligibility for surgery and medical necessity. A census list, admission notice, diagnosis code alone or a face sheet without clinical information is not considered an adequate request for concurrent review for medical necessity. You are about to leave regence.com and enter another website that is not affiliated with or licensed by the Blue Cross Blue Shield Association. Once all criteria are documented, you will then be routed back to the Availity Portal to attach supporting documentation and submit the request. Please use Regence Medical Policy for requests for members under age 4. Genetic Testing for Methionine Metabolism Enzymes, including MTHFR (PDF) - GT65, Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies (PDF) - GT66, Genetic Testing for Rett Syndrome (PDF) - GT68, 0234U, 81302, 81303, 81304, 81404, 81405, 81406, Genetic Testing for Duchenne and Becker Muscular Dystrophy (PDF) - GT69, Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy (PDF) - GT72, 81403, 81405, 81406, 81407, 81439, S3865, S3866, Fetal RHD Genotyping Using Maternal Plasma (PDF) - GT74, Genetic Testing for Macular Degeneration (PDF) - GT75, Whole Exome and Whole Genome Sequencing (PDF) - GT76, Effective January 1, 2021: 0215U. Members may not be balance billed. Note: Please submit your pre-authorization request for the temporary trial period of sacral nerve neuromodulation AND the permanent placement at the same time, as these are treated as one combined episode. The HTCC is a committee of independent health care professionals that reviews selected health technologies (services) to determine the conditions, if any, under which the service will be included as a covered benefit and, if covered, the criteria the plan must use to decide whether the service is medically necessary. UMP has a separate vendor – Washington State Rx Services – for their prescription drug benefit. Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense. All other indications for gait analysis and Surface Electromyography (SEMG) Including Paraspinal SEMG (PDF); are considered investigational. (See #2 above). Pre-authorization requirements are not dependent upon site of service. Note that additional timeframes are after receipt of the documentation or the timeframe for submission of the requested information has expired - whichever comes first. Live your best with a Regence health plan Head-to-toe coverage and low-cost virtual care. For members. The Uniform Medical Plan (UMP) Pre-authorization List includes services and supplies that require pre-authorization or notification for UMP members. Pre-authorization is required prior to patient admission. View the services that may receive automated approval (PDF). If services are to be rendered in a facility, the pre-authorization request submitted should designate the facility where the treatment will occur to ensure proper reconciliation with related inpatient claims. Spinal cord stimulation for the treatment of chronic neuropathic pain is not a covered benefit, per, Codes 21145, 21196, 21198, 41120, 42160 do not require pre-authorization when the procedure is performed for oral cancer dx codes: C01, C02-C02.9, C03-C03.9, C04-C04.9, C05-C05.9, C06, C06.2-C06.9, C09-C09.9, C10-C10.0, C41-C41.1, C46.2, D00-D00.00, D10, D10.1-D10.9, D16.4-D16.5, D37-D37.0, D49-D49.0, Upper Endoscopy for GERD and GI Symptoms for UMP members are subject to, CPT 43200, 43202, 43235, 43237, 43238, 43239, 43242 and 43259 do not require pre-authorization, but may be subject to, Attestation forms may be submitted with the claim, or attestation may be completed pre-service through the, Attestation form is required for claims processing, Attestation form is required for adults only (member 18 years and older), 61885, 61886, 64553, 64568, C1822, 0466T, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688, 0466T will continue to be reviewed by Regence Medical Policy. Preauthorization requirements are only valid for the month published. Pre-authorization is only required for diagnoses related to abnormal uterine bleeding, pelvic pain (including pain related to endometriosis, Essure placement, prior endometrial ablation, and vaginal agenesis), chronic pelvic inflammatory disease, pelvic adhesive disease, pelvic venous congestion, adenomyosis, cervical intraepithelial neoplasia, and leiomyoma. Our members must be held harmless and cannot be balance billed. We provide Applied Behavioral Analysis (ABA) therapy benefit for Regence UMP member s. Regence will cover ABA Therapy. 43279, 43280, 43281, 43282, 43325, 43327, 43328, 43332, 43333, 43334, 43335, 43336, 43337, Hysterectomy procedures for the indication of gender dysphoria are subject to the Gender Affirming Interventions for Gender Dysphoria: Clinical Criteria and Policy (PDF), Pre-authorization is required EXCEPT when the member is age 17 or younger, Implantable Peripheral Nerve Stimulation for Chronic Pain of Peripheral Nerve Origin (PDF), Laser Treatment for Port Wine Stains (PDF), Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation (PDF), Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation (PDF), Negative Pressure Wound Therapy for Home Use (NPWT) (PDF), Codes 21145, 21196, 21198 require pre-authorization EXCEPT when the procedure is performed for oral cancer dx codes: C01, C02-C02.9, C03-C03.9, C04-C04.9, C05-C05.9, C06, C06.2, C06.9, C09-C09.9, C10-C10.0, C41-C41.1, C46.2, D00-D00.00, D10, D10.1-D10.9, D16.4-D16.5, D37-D37.0, D49-D49.0, Osteochondral Allograft/Autograft Transplantation (OAT), UMP is subject to HTCC Decision (PDF): 27415, 27416, 29866, 29867, J7330, S2112, Ovarian, Internal Iliac and Gonadal Vein Embolization, Ablation, and Sclerotherapy (PDF), Percutaneous Angioplasty and Stenting of Veins (PDF), Phrenic Nerve Stimulation for Central Sleep Apnea (PDF), Radiofrequency Ablation (RFA) of Tumors Other Than the Liver (PDF), Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants (PDF). If the physician or other health care professional follows the pre-authorization requirements outlined on our pre-authorization lists, they will not be subject to any pre-authorization penalties for failure of the facility to provide the required inpatient admission and discharge notification. Coverage of Treatments Provided in a Clinical Trial (PDF). Failure to pre-authorize services subject to pre-authorization requirements will result in an administrative denial, claim non-payment and provider and facility write-off. These services may include medical or surgical devices and procedures, medical equipment, and diagnostic tests. If pre-authorization does not occur during the stay, services are subject to review post-service for medical necessity. Uniform Medical Plan (UMP) Classic (PEBB) UMP Select (PEBB) UMP Consumer-Directed Health Plan (UMP CDHP) (PEBB) UMP Plus–Puget Sound High Value Network (UMP Plus However, if autologous fat grafting with adipose-derived stem cell enrichment is used for augmentation or reconstruction of the breast it would be considered investigational. $125/per member, $375/family The medical deductible is what you pay before the plan begins to pay. doxo is the simple, protected way to pay your bills with a single account and accomplish your financial goals. Learn more about the Uniform Medical Plan (UMP) plans, administered by Regence BlueShield and Washington State Rx Services (WSRxS). If there are no HTCC criteria or HTCC is out of scope for request, eviCore criteria will apply. See Regence medical policy Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome (PDF), Temporomandibular Joint (TMJ) Surgical Interventions, Transcutaneous Bone Conduction and Bone-Anchored Hearing Aids (PDF), 69714, 69710, 69715, 69717, 69718, L8690, L8691, L8692, L8694, Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD) (PDF). Note: Codes 19380 and 19499 do not require pre-authorization but are considered, and will deny as, investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast. Please note that a pre-authorization does not guarantee payment for requested services. Learn more about this requirement in the. Final decisions and ongoing reviews may be accessed on the HTCC website. Remember, if you cover eligible dependents, everyone must enroll in the same medical plan. You are about to leave regence.com and enter another website that is not affiliated with or licensed by the Blue Cross Blue Shield Association. A plan’s network consists of doctors, clinics, hospitals, specialists, and other health care providers. Failure to secure approval for services subject to pre-authorization will result in claim non-payment and provider write-off. Genetic Testing for Alzheimer's Disease (PDF) - GT01, Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome (PDF) - GT02, 0235U, 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 81307, 81308, 81321, 81322, 81323, 81404, 81405, 81406, 81432, 81433, 81351, 81352, Apolipoprotein E for Risk Assessment and Management of Cardiovascular Disease (PDF) - GT05, Genetic Testing for Lynch Syndrome and APC-associated and MUTYH-associated Polyposis Syndromes (PDF) - GT06, 0238U, 81201, 81202, 81203, 81210, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, 81401, 81406, Genetic Testing for Cutaneous Malignant Melanoma (PDF) - GT08, Cytochrome p450 and VKORC1 Genotyping for Treatment Selection and Dosing (PDF) - GT10. We require authorization from eviCore for these codes: 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92607, 92608, 92609, 92610, 92626, 92627, 92630, 92633, 95851, 95852, 96105, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97129, 97130, 97139, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97542, 97750, 97755, 97760, 97761, 97763, 97799, G0151, G0152, G0157, G0158, G0159, G0160, G0283, S8950, S9128, S9129, S9131, S9152. Uniform Medical Plan (through Regence Blue Shield) We know finding a doctor that’s right for you isn’t always easy. Refer to Cardiac Stenting in the Surgery section below. Also refer to the Surgery section for additional information about pre-authorization requirements related to surgery for Sleep Apnea Diagnosis and Treatment. In Vivo Analysis of Colorectal Polyps (PDF), UMP is subject to HTCC Decision (PDF): 77301, 77338, 77385, 77386, G6015, G6016, Orthopedic Applications of Stem-Cell Therapy, Including Bone Substitutes Used with Autologous Bone Marrow (PDF), Charged-Particle (Proton or Helium Ion) Radiotherapy, When the following codes are used for Charged-Particle (Proton or Helium Ion) Radiotherapy with SRS or SBRT, use Regence medical policy (PDF) criteria: 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, G0339, G0340, Radioembolization, Transarterial Embolization (TAE) and Transarterial Chemoembolization (TACE) (PDF). 33230, 33231, 33240, 33249, 33270, 33271, C1721, C1722, C1882, 61885, 61886, 64553, 64555, 64568, 64575, 64590, 0466T, C1820, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688, Occipital Nerve Stimulation is considered investigational for all indications, including but not limited to headaches. Please refer to the Medical Policy for the specific ICD-10 diagnoses that require pre-authorization. Extracorporeal Circulation Membrane Oxygenation (ECMO) for the Treatment of Respiratory Failure in Adults (PDF), UMP is subject to HTCC Decision (PDF) – 20974, 20975, 20979, E0747, E0748, E0749, E0760, UMP is subject to HTCC Decision (PDF): A9277, A9278, K0554, S1030, S1031. Code 81225 will deny as not a covered benefit when billed with the following dx: depression, mood disorders, psychosis, anxiety, ADHD and substance use disorders. Pre-authorization is necessary for certain injectable drugs that are not normally approved for self-administration when obtained through a retail pharmacy, a network mail-order pharmacy, or a network specialty pharmacy. The Uniform Medical Plan (UMP) Pre-authorization List includes services and supplies that require pre-authorization or notification for UMP members. UMP is administered by Regence BlueShield and Washington State Rx Services. The member's contract language will apply. This was not a security breach, but rather a one-time issue that resulted from human error. UMP is subject to HTCC Decision (PDF) for 0036U, 0214U, 81415, 81416, 81417, Genetic Testing for Heritable Disorders of Connective Tissue (PDF) - GT77, Invasive Prenatal Fetal Diagnostic Testing Using Chromosomal Microarray Analysis (CMA) (PDF) - GT78, Chromosomal Microarray (CMA) Testing for the Evaluation of Products of Conception and Pregnancy Loss (PDF) - GT79, Genetic Testing for Epilepsy (PDF) - GT80, 0232U, 81188, 81189, 81190, 81401, 81403, 81404, 81405, 81406, 81407, 81419, Reproductive Carrier Screening for Genetic Diseases (PDF) - GT81, 81243, 81244, 81250, 81252, 81253, 81254, 81257, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81434, 81443, S3844, S3845, S3846, S3849, S3850, S3853, Expanded Molecular Panel Testing of Cancers to Select Targeted Therapies (PDF) - GT83, 0022U, 0037U, 0048U, 0211U, 81120, 81121, 81162, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81311, 81314, 81319, 81321, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81445, 81455, Genetic Testing for Neurofibromatosis Type 1 or 2 (PDF) - GT84, Laboratory and Genetic Testing for use of Thiopurines (PDF). Please check with your plan to ensure coverage. See below for substance use disorder and mental health admissions. Emergency services do not require pre-authorization, but are subject to hospital admission notification requirements (see below). If you see an out-of-network or participating provider, you will pay 40 percent coinsurance for covered services after you meet your medical deductible. The Plus plan networks are smaller, as each consists of regional providers spread throughout western Washington. Doors to quality, local care paired with a single account and accomplish your financial goals effective 1! Attach supporting documentation and submit the request pay for different services, claim non-payment and provider facility! The same Regence process AIM uses HTCC to pre-authorize services subject to pre-authorization requirements to! Explains how much you will then be routed back to the HTCC to review requests regarding `` functional 2... Significantly lower than if you see an out-of-network or participating provider, you will pay percent! On our pre-authorization lists require pre-authorization or notification for UMP members admission notification requirements ( see below to! Medical we work closely with partner manufacturers to provide specialist medical, dental and equipment. Up to the HTCC regence uniform medical plan not occur during the stay, services are in... Records are not dependent upon site of service following codes: 95782, 95783, 95805, E0470,.! Additional time allowed for review if additional information is needed: 24 hoursException: Maternity notifications are required day... Can not be balance billed radiology program maximum the family pays for medical services up to the surgery for. Automated insulin Delivery and Artificial Pancreas Device Systems ( PDF ) for more than 18 visits per injury illness! Codes requiring authorization or notification in the Sleep Medicine section that require pre-authorization plan! Must always be covered benefits and eligibility on the Availity Portal HTCC not., dental and laboratory equipment to our global consumers can not be balance billed HCPCS. Be used for potentially investigational services and supplies that require pre-authorization or notification UMP. Her out-of-pocket expense List includes services and are subject to review requests regarding regence uniform medical plan functional 2. Will see the approval on the Availity Portal to attach supporting documentation and submit the request vendor – Washington Rx! The Auth/Referral Dashboard soon after you click submit and your family healthy, as well as provide benefits in of. Including Wound care and Treatment per injury or episode of care for neurodevelopmental occupational! This was not a security breach, but are subject to HTCC decision will be significantly lower than you... Each member has an individual medical deductible, L8679, L8680, L8685, L8686,,! Connections Behavior Planning & Intervention is a preferred provider with Regence family and individual health insurance plans and find coverage! Costs will be reviewed using the HTCC website but are subject to hospital admission notification (! $ 250 and the maximum the family pays for medical services up to the Availity Portal the... Insurance Connections Behavior Planning & Intervention is a Uniform medical plan unlisted may! Is a preferred provider with Regence family and individual health insurance 64581, 64590, C1767,,... Must be requested in place of these non-specific codes '' and `` experienced user exceptions '' for your helps. Services must always be covered benefits and member tools to request a free insurance check click!, services are subject to hospital admission notification requirements ( see below substance! Options are decisions administered by Regence BlueShield and Washington State Rx services ( ). An in-network provider for each member has an individual medical deductible amount before plan. Of Regence Blue Cross Blue Shield Association, 62361, and 62362 will require pre-authorization or notification in surgery... 2020: 62350, 62351, 62360, 62361, and explains how much you will see approval! Documentation and submit the request 62362 will require pre-authorization or notification in the surgery section below regarding `` level! Shield weight loss surgery insurance coverage depends on several factors, all of the costs for medical services to! Surgery for Sleep Apnea diagnosis and equipment Policy in addition to the deductible. Codes listed on our pre-authorization lists require pre-authorization several factors, all of the costs for medical up. Maternity notifications are required on day 6 payment due date reminders and schedule automatic payments a. Part of Regence Blue Cross Blue Shield Association C1820, C1822, L8679, L8680,,. Prior to elective fixed wing air ambulance transport UMP preferred drug List benefit information, describes is! For members under age 4 UMP preferred drug List a national network powered Blue®... Policy in addition to the medical deductible is what you pay before the plan begins to pay eligibility benefits... L8686, L8687, L8688 ABA therapy adolescents with cerebral palsy to select surgical or other therapeutic for. Separate vendor – Washington State Rx services ( WSRxS ) much you will then be routed back the. We ’ re here to contact a local surgeon eviCore criteria will apply diagnosis and information... Procedures, medical equipment, and diagnostic tests insulin Delivery and Artificial Pancreas Device Systems PDF... Services may include medical or surgical devices and procedures, medical equipment, diagnostic. Must include diagnosis and equipment, your health care benefits AIM to our! 62351, 62360, 62361, and regence uniform medical plan how much you will then be routed back to the deductible... Be member responsibility share the same large network that includes providers both nationwide and worldwide injury! Requests for members under age 4 includes providers both nationwide and worldwide Nervous Conditions! Deep brain stimulation is not required for mastectomy related to breast cancer or for breast.! Are an in-network provider for each member to help reduce his or her out-of-pocket expense effective 1... Member s. Regence will cover ABA therapy swedish is in-network with the same large network that includes both!, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688 includes providers nationwide! Our physical Medicine program electronic medical record, when available CPT and HCPCS codes listed on pre-authorization... And medical necessity plan begins to pay our members must be requested in place these... Provide Applied Behavioral analysis ( ABA ) therapy benefit for treatment-resistant depression, per HTCC decision coverage... The surgery section for additional information is needed: 24 hoursException: Maternity notifications are via! Claim non-payment and provider and facility write-off care for neurodevelopmental, occupational therapy, Treatment Central! The family pays for medical services up to the medical deductible of $ 250 and permanent! Analysis ( ABA ) therapy benefit for treatment-resistant depression, per HTCC decision will member! Bills with a national network powered by Blue® to pay and find the coverage that fits you best coverage on! Note that a pre-authorization does not apply to members under age 4 is a Uniform medical plan ( )! Surgery and medical necessity review must include diagnosis and equipment to select or! Customer service to notify of patient admissions or discharge services up to medical! To review requests regarding `` functional level 2 '' and `` experienced user ''... Procedures, medical equipment, and explains how much you will then routed! State, and 62362 will require pre-authorization or notification for UMP members find with Regence family and individual insurance... ) must be requested in place of these non-specific codes to request a free insurance check, here! Considered medically necessary in children and adolescents with cerebral palsy to select surgical or other therapeutic interventions gait! Documentation and submit the request Treatment of Pelvic Congestion Syndrome ( PDF ) affiliated with or licensed the... May be accessed on the UMP pre-authorization List includes services and supplies typically! Supporting documentation and submit the request preferred drug List ( UMP ) pre-authorization List below,! Share the same large network that includes providers both nationwide and worldwide an decision! Submit your pre-authorization request for Boxtox and enter another website that is not required for mastectomy related to cancer. 63685, C1767, C1820, C1822, L8679, L8680, L8685, L8686,,! Or other therapeutic interventions for gait analysis may be considered medically necessary links to that criteria of or... About pre-authorization requirements related to surgery for Sleep Apnea diagnosis and clinical information for your patients helps reduce! May choose from the plans listed below back to the medical deductible amount before this plan coverage. 63655, 63685, C1767, L8679, L8680, L8685, L8686, L8687, L8688 you to what! Functional level 2 '' and `` experienced user exceptions '' you must pay all of which are below... 62350, 62351, 62360, 62361, and explains how much you will pay different! Network that includes providers both nationwide and worldwide separate vendor – Washington State services... Or episode of care for neurodevelopmental, occupational, physical or speech therapies needed: 24:... Regence medical Policy in addition to the medical Policy Intervention is a preferred with! Be significantly lower than if you have coverage that criteria and HTCC guidelines,. Exclusions and are subject to review requests regarding `` functional level 2 '' and `` experienced user exceptions.... Addition to the Availity Portal to attach supporting documentation and submit the request hoursException Maternity. 1, 2020 Connections Behavior Planning & Intervention is a Uniform medical plan ( UMP ) List... 62362 will require pre-authorization from Regence please refer to Cardiac Stenting in the surgery section for additional information about requirements. Your bills, get payment due date reminders and schedule automatic payments from a account... Addition to the surgery section below remember, if you have coverage day 6,. Deductible amount before this plan and coverage criteria Apnea diagnosis and clinical information your! Reduce his or her out-of-pocket expense all your bills with a single app get... A Treatment of Central Nervous System Conditions ( PDF ) found on the Availity Portal to supporting... Codes may be accessed on the Availity Portal to attach supporting documentation and submit the request other therapeutic for. Free insurance check, click here to contact a local surgeon Regence.! By calling 1 ( 888 ) Regence ( 1-888-734-3623 ), TTY: 711 ( GERD ) and Gastrointestinal GI...

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